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Speaker 1: This is let's be clear, who's Shannon Dohrney. Hello, Let's

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Speaker 1: be clear listeners, this is not a super familiar voice.

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Speaker 1: My name is Rache. I'm a brain to resurgeon. Remember

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Speaker 1: me probably when being on a guest in Shannon's podcast

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Speaker 1: earlier this year. It's definitely hard for us to be

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Speaker 1: without her, to be without her light, and I feel

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Speaker 1: for you, folks. But here we get to try to

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Speaker 1: put on further this this tradition she started of being

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Speaker 1: upfront with information and explaining things to people. I'm honored

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Speaker 1: to have been part of Shannon's treatment team as a resurgeon,

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Speaker 1: and so I'm your guest host today, and so this

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Speaker 1: is a good time to put some more information out there.

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Speaker 1: With a breast cancer aware this month, So I've been

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Speaker 1: giving some questions from listeners and readers about cancer and

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Speaker 1: I'm going to do my best to answer them. So

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Speaker 1: someone wrote in what's the difference between stage three and

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Speaker 1: stage four? So cancers to the body are staged, and

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Speaker 1: it generally involves the idea of how far outside the

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Speaker 1: organ of origin things are. So like a lung cancer

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Speaker 1: that spreads to the other lung or lymphotes outside the

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Speaker 1: lung or to other organs. Stage four generally means like

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Speaker 1: a totally different organ, like a lung cancer that spreads

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Speaker 1: the liver, or breast cancer that spreads to the brain.

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Speaker 1: That's usually the difference between the stage three and a

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Speaker 1: stage four. Someone asks what does a cancer look like

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Speaker 1: when you operate on them, So they all actually look

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Speaker 1: a little bit different, and sometimes even for a breast cancer,

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Speaker 1: they can look a little different. It depends a little

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Speaker 1: bit on how aggressively something is growing. Sometimes things are

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Speaker 1: pretty vascular and growing and really pushing brain around a lot,

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Speaker 1: and once in a while you have ones that are

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Speaker 1: a little bit more slower growing and encapsulated and kind

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Speaker 1: of round. You typically can tell the cells look very different,

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Speaker 1: doesn't look like normal brain at all. When you see

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Speaker 1: a tumor and it has some color and texture differences.

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Speaker 1: Sometimes a tumor can be a little bit firmer than

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Speaker 1: regular brain, so you can carve out that pathway, that

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Speaker 1: line between the brain tumor and the normal brain. Rarely

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Speaker 1: there can be hemorrhage associated with it, So sometimes you

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Speaker 1: can operate within this blood clot and then you find

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Speaker 1: tumor tissue to remove. Sometimes a tumor can be cystic.

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Speaker 1: Sometimes the cells can create some fluid and you want

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Speaker 1: to take all that out, and sometimes there's a little

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Speaker 1: bit of a wall to be removed. Sometimes really it

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Speaker 1: just makes fluid that pushes on the normal brain. So

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Speaker 1: we use all these kinds of differences to try to

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Speaker 1: help us remove everything we can. Most of the time

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Speaker 1: when we're there at surgery, between things we use to

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Speaker 1: help us, like MRI guidance and an operating microscope. We

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Speaker 1: use this big microscope that offers a lot of illumination

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Speaker 1: and a lot of magnification. We can see the edge

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Speaker 1: of the tumor. There are always a few cells left

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Speaker 1: behind that we can't see that there are actually smaller

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Speaker 1: than you can see in the microscope. So typically people

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Speaker 1: need some amount of radiation around the surgery. Sometimes we

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Speaker 1: do that afterwards. Sometimes if it's a very small spot,

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Speaker 1: we think our targeting is better if we do a

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Speaker 1: small doser radiation beforehand and then do surgery. Also, if

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Speaker 1: we're at surgery and any cells escape if someone already

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Speaker 1: had radiation, we think that those cells as not really

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Speaker 1: that viable, not that alive, So sometimes we would take

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Speaker 1: all that into account that there's cells there. But one

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Speaker 1: part of the question is is can you see cells

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Speaker 1: spread in the brain. You really can't see the exact cells.

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Speaker 1: They have to be large enough to be a tumor.

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Speaker 1: Sometimes we use other adjuncts at surgery, like there's not

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Speaker 1: as many interopreative MRIs like tak an MRI in surgery,

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Speaker 1: and really you can't operate inside an MRI safely right.

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Speaker 1: Many surgical tools are some type of metal, and even

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Speaker 1: if you choose one that doesn't create a lot of

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Speaker 1: magnetic signal, kind of dangerous to do that. But sometimes

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Speaker 1: we use an ultrasound because you can use an ultrasound

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Speaker 1: right on the brain itself and see as you're working

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Speaker 1: that you took all the tumor out. So those are

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Speaker 1: some of the things we use to make sure we

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Speaker 1: do our best job. Someone asks how long does it

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Speaker 1: take for cancer to metastasize, so they offer the spread

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Speaker 1: of timing days, weeks, months, or year. So most cancers

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Speaker 1: don't spread in days. So it is rare that we

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Speaker 1: can find someone that has had a new diagnosis of

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Speaker 1: a cancer and they'll have several sites of the disease

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Speaker 1: at the same time, but it usually still would be

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Speaker 1: something over time has spread to that not usually days.

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Speaker 1: I've definitely seen people where it can be diagnosed with

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Speaker 1: a cancer like a breast cancer and a brain metastis.

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Speaker 1: At the same time, I've also seen people where it

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Speaker 1: can be more than five or more years since they're

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Speaker 1: cancer diagnosis before something happens. There's a lot we think

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Speaker 1: that has to do with how much people fall up

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Speaker 1: with their doctor and get appropriate scans and things and

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Speaker 1: appropriate treatment, and we usually can find little changes happening

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Speaker 1: before there's widespread disease. That once in a while it's

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Speaker 1: people who don't quite keep up all the imaging or

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Speaker 1: kind of disappear a little bit from the oncologists and

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Speaker 1: start taking some strange therapies that sometimes they can come

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Speaker 1: back with a lot of things going on. But it

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Speaker 1: is part of why for a lot of cancer you

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Speaker 1: really use the term remission. Like when people have had

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Speaker 1: a lot of treatment and things are quiet and we

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Speaker 1: still watch them with some visits and scans, they can

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Speaker 1: be in a remission. And for many of these cancers,

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Speaker 1: it's hard to use the word cure. Care would imply

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Speaker 1: we shake your hand and give you a U and

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Speaker 1: say go live your life. Don't get another test again.

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Speaker 1: I mean, we do worry that things can rear their

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Speaker 1: ugliheads again. So sometimes I even have people, you know

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Speaker 1: that I've been following for more than a decade, just

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Speaker 1: making sure that they stay out of trouble. See, does

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Speaker 1: weight have anything to do with the likeli of getting cancer?

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Speaker 1: I'm not aware of some that's super clear for that.

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Speaker 1: I mean, we do think of both how people respond

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Speaker 1: to a disease and its treatments might have a little

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Speaker 1: bit to do with health, you know, like some amount

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Speaker 1: of focus on exercise and diet. It's not really that

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Speaker 1: there's something as simple as a tumor starvation diet. I've

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Speaker 1: had someone before where the spouse the patient on the

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Speaker 1: tumor strivation diet. The only thing starving was the patient.

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Speaker 1: The pumber can find a way to grow, So it's

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Speaker 1: not as simple as the diet. Sometimes in the Internet

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Speaker 1: people even talk about, oh, sugar feeds cancer, And there's

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Speaker 1: a little bit to that. I mean in your bloodstream. Also,

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Speaker 1: your body makes glucose to feed the brain, right, it

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Speaker 1: doesn't your brain doesn't run on protein purely, so you

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Speaker 1: can't really eliminate sugar from everything. And clearly it's one

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Speaker 1: thing to say, you know, nobody needs three slices of

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Speaker 1: chocolate cake to day, but sugar from fruits it is

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Speaker 1: always going to be a part of a good diet.

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Speaker 1: And so sometimes too, when people are going through surgeries

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Speaker 1: and treatments, they deserve a treat here and there. You know,

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Speaker 1: to deny someone all twreats doesn't always help quality of life.

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Speaker 1: Part of our goal should be quality of life, not

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Speaker 1: just pure quantity of belief. There's a question about itchy

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Speaker 1: nipples as a sign of breast cancer. Well, I'm going

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Speaker 1: to be the best one to go into all of

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Speaker 1: those as a neurosurgeon, but I haven't heard that one before.

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Speaker 1: That's a big warning sign. Note Okay, someone asks what

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Speaker 1: is the best case scenario when a patient goes to

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Speaker 1: you to get a tumor removed? So many times what

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Speaker 1: we look at is this distinction between a solitary brain

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Speaker 1: metasis or several brain fantast disease. And while Shannon actually

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Speaker 1: had a couple spots there, a lot of them are

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Speaker 1: very small. There was one major one, and so sometimes

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Speaker 1: we think if there's one major metastasis and we perform surgery,

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Speaker 1: that we're attacking like the major side of disease in

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Speaker 1: the body. There is this part too that taking some

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Speaker 1: tumor out from the current disease state really helps. To

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Speaker 1: the hero on cologist dart Piro, it really helps give

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Speaker 1: us both an idea for sure that we're seeing tumor.

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Speaker 1: Also it gets another chance for us to look the

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Speaker 1: molecular signas to their tumor case. It changes the idea

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Speaker 1: of any targeted therapy or immuni therapy. So with her,

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Speaker 1: fortunately we were able to remove that safely and she

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Speaker 1: did well with surgery. She was pretty tough. She's been

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Speaker 1: through a few surgeries, so she is pretty tough. And

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Speaker 1: then we're able to treat the other tiny sites with

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Speaker 1: radiation and she spawned well to that. So in Sham's case,

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Speaker 1: there was this big advantage that we took with surgery

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Speaker 1: that her brain was quiet for a long time, and

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Speaker 1: really what we thought was going on with her is

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Speaker 1: that she had systemic disease. That was the problem. I

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Speaker 1: remember actually when we did our podcast together. Neurologically, she

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Speaker 1: was doing great, her brain was terrific, she was speaking well,

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Speaker 1: she was thoughtful, but she said I kind of have

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Speaker 1: this new pain and that they were kind of working

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Speaker 1: that up and it was that worry, that sign that

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Speaker 1: something else is going on on the body. The pain

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Speaker 1: was on the body, her brain was doing fine. There

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Speaker 1: is that advantage in the brain that most of the time,

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Speaker 1: between surgery and radiation we can control metallic disease. It

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Speaker 1: doesn't always happen exactly the same and the rest of

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Speaker 1: the body, and so sometimes looking again at that molecular

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Speaker 1: signature helps guide us onto the next step. Once in

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Speaker 1: a while. It's that thing that we think of the

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Speaker 1: removing a solitary brain metastasis is kind of like resetting

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Speaker 1: the clock. Like if you took all the people with

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Speaker 1: lung cancer with and without brain metastases, clearly the survival

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Speaker 1: would be different. But we think that if we have

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Speaker 1: someone with really one metastas that we can remove safely

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Speaker 1: and give focused radiation to the edges there, we kind

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Speaker 1: of reset the prognosis clocked, almost as if they didn't

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Speaker 1: have that metastasis in the first place. And then clearly

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Speaker 1: when you have someone with several metastasy, you don't have

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Speaker 1: that advantage. Sometimes when we operate on people with several metastases,

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Speaker 1: we operate on one or two of the largest ones

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Speaker 1: that might be hard to treat with radiation or ones

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Speaker 1: that are very symptomatic. For example, there could be one

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Speaker 1: really pressing on the most area and with like a

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Speaker 1: lot of swelling. That someone has weakness, and if we

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Speaker 1: can take that out, we can make them stronger. So

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Speaker 1: we plan those surgeries to help quality of life, but

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Speaker 1: it may not always change their prognosis if they're multiple

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Speaker 1: metastasies different than that solitary scenario. Those are some of

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Speaker 1: the ways we look at try to make the best

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Speaker 1: of a situation for a patient and keep them healthy.

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Speaker 1: Someone asked, how soon can you tell of a surgery

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Speaker 1: was a success? In general, you know a lot about

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Speaker 1: surgery within the first twenty four hours, so you know,

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Speaker 1: if I would know if a patient is neurologically worse

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Speaker 1: or not, that if things like brain swelling or bleeding

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Speaker 1: or even stroke, which is a risk of surgery. It's

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Speaker 1: an uncommon risk. I mean, when you tinker with the

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Speaker 1: brain for surgery, a stroke can happen about one percent

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Speaker 1: of the time you perform kind of surgery. We would

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Speaker 1: know that generally in the first twenty four hours. There

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Speaker 1: is partly a different sun of success in terms of

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Speaker 1: like does a tumor grow back in things, but usually

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Speaker 1: between surgery and focus radiation, we can prevent a tumor

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Speaker 1: from coming back at that. One side part of our

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Speaker 1: job later with multiple rain and arize is to look

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Speaker 1: at the rest of the brain to make sure there

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Speaker 1: are no other sense. Okay, someone asks, are there natural

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Speaker 1: foods that keep cancer away? Well, it's a little bit unclear.

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Speaker 1: There are some studies that you'll see that talk about

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Speaker 1: either the rate of cancer or the response to cancer

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Speaker 1: and evolvays some things, but it's not really clear enough

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Speaker 1: that there's a particular food that does that. Now, clearly

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Speaker 1: there's probably a part of us as Americans eating like

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Speaker 1: regular food and you know, fresh fruits and vegetables and

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Speaker 1: things that are from cooking, and there's probably an amount

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Speaker 1: of processed foods that we're a little bit not in

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Speaker 1: control of exactly what's in there and sugar content and

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Speaker 1: stuff like that. But I wouldn't as necessarily say that

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Speaker 1: there's one super particular thing that people should tank see.

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Speaker 1: When breast cancers be on the point of treatment, what

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Speaker 1: does a patient actually die from It can depend, so

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Speaker 1: it's a little bit more rare for people to succumb

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Speaker 1: to brain metastases. Usually we can control them between surgery

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Speaker 1: and radiation and sometimes Now there are targeted agents for

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Speaker 1: breast cancer, a number of different targeted medicines that can

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Speaker 1: get into the brain a little bit or when people

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Speaker 1: qualify for immunotherapy, right, so chemotherapy being medicines that hurt

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Speaker 1: tumor cells a little bit different than immunotherapy, medicine to

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Speaker 1: stimulate your immune system to fight the tumor better. Not

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Speaker 1: all cancers have a good signal that they would respond

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Speaker 1: to immunotherapy, but they can. And then even if therapy

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Speaker 1: can get into the brain, sometimes we even use it

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Speaker 1: on primary brain tumors, so sometimes that can be the

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Speaker 1: stuff that really helps fight things. I guess the second

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Speaker 1: part of that is the cancer is the cancer yourself.

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Speaker 1: For organ failure, so not most people really die pure

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Speaker 1: organ failure. So real organ failure we're like your kidney

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Speaker 1: shutting down, your liver shutting down. Happens when people have

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Speaker 1: some type of an infection and you know, bloodstream infection

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Speaker 1: called sepsis. Most of the time, when breast cancer patients

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Speaker 1: start to peter out, it's that the disease is growing

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Speaker 1: and just taking a toll on their body for their

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Speaker 1: energy reserves. And making them sick. It can be some

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Speaker 1: organ involvement. It's not usually totally organ failure. Can you

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Speaker 1: tell when someone only has a few weeks left to live?

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Speaker 1: Yes and no. I mean sometimes you get a sense

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Speaker 1: on someone who really feels that their energy is very

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Speaker 1: depleted and they don't feel well. They haven't responded to

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Speaker 1: the therapy. Once a while, when people have limited ability

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Speaker 1: to speak, they can still tell you what they want

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Speaker 1: and feel like they're going through. When people sometimes just

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Speaker 1: gradually want to do less and eat less than that

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Speaker 1: can be a sign they know there are things going

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Speaker 1: on that are not going in the right direction. But

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Speaker 1: sometimes it's hard. Like humans, we have this weakness in prognostication.

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Speaker 1: We can't always pull the future out Like I want

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Speaker 1: my crystal ball to be working, but it's really well,

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Speaker 1: like a crystal ball that has some cracks in it.

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Speaker 1: Things like that. See, cancer treatment can weaken the body

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Speaker 1: of the immune system, So how do we know whether

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Speaker 1: it's doing more good than harm. Well, some of that

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Speaker 1: is and really seeing people and try to balance the

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Speaker 1: quality of life. So more and more it's the priority

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Speaker 1: to make sure people have a good quality of life

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Speaker 1: and not really just you hammering them with treatments to

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Speaker 1: get more quantity of life. So as people are fatigued

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Speaker 1: or have different medical side effects from treatment, sometimes we

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Speaker 1: will dose reduce the treatment. And sometimes even if the

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Speaker 1: treatment was roughly working, if it's hurting someone more than

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Speaker 1: it's helping, we may have to change that. So it's

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Speaker 1: a lot of contact with a good doctor and making

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Speaker 1: sure we stay in touch about side of and things.

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Speaker 1: Should someone with cancer exercise, absolutely so, we both think

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Speaker 1: that that's good for your mental health, but the whole

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Speaker 1: idea of just oxygenation and stimulating the good cells in

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Speaker 1: the body, right, We think that exercise and movement is

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Speaker 1: good for the immune system and helping you fight the tumor.

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Speaker 1: In general, there's no disease that I know of where

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Speaker 1: strict bed rests for prolonged times is good and lots

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Speaker 1: and lots of bedrests put you at risk for other problems.

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Speaker 1: So when people are in the hospital after surgery it

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Speaker 1: can't walk around very well. We do various things to

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Speaker 1: stimulate their blood from being too thick and getting blood clots.

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Speaker 1: There are squeezers we put on the legs are rarely

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Speaker 1: if it's days later. Some people even need light blood

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Speaker 1: thinner to make sure they don't develop these blood clots

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Speaker 1: and things like that. When you're under prolonged bed rest,

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Speaker 1: then there are risks for blood clots and it can

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Speaker 1: be dangerous. Also cancer in general, we think cancervations are

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Speaker 1: a little more prone to blood clots than others, even

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Speaker 1: more so, like strict bed rest can be a risk

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Speaker 1: for cancervations. As it true you qualify for lifetime disability

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Speaker 1: if you're diagnosed with cancer, I'm unaware of that being

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Speaker 1: the case. I think there are definitely people with different

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Speaker 1: insurance policies, and then there's a part where it can

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Speaker 1: depend where you are in your cancer course. Certainly someone

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Speaker 1: has more and more metastics than unable to work in

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Speaker 1: things like that. There's things that for disability, but not

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Speaker 1: an automatic you know, the first sign of cancer, it

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Speaker 1: is not an automatic lifetime disability. Do I think anything

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Speaker 1: about deodorant in cases of breast cancer. I haven't heard

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Speaker 1: that one either. I haven't heard any breast cancer oncologists

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Speaker 1: recommend that everyone stops deodorant. I don't know that that's

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Speaker 1: the one. I certainly appreciate it when patient's were deodorant.

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Speaker 1: Do you think the metal insides women's brass could potentially

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Speaker 1: be a factor causing breast cancer. That one's a tough

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Speaker 1: one for me. I'm not sure I would call myself

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Speaker 1: the expert in that, but I'm unaware of any type

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Speaker 1: of recall, and you know, this country is pretty safe

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Speaker 1: with that stuff, so I think if there are any

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Speaker 1: real evidence for that, it would be something that'd be

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Speaker 1: changed pretty quickly. Also, you know, I assume they're talking

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Speaker 1: more like the underwire than like the class and stuff

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Speaker 1: like that, which sometimes the classes are in the back.

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Speaker 1: But I'm not aware of anything that says that the

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Speaker 1: metal has anything to do with it. So once in

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Speaker 1: a while we meet patients that have a couple of

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Speaker 1: preset ideas in their head about what cancer is like

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Speaker 1: and what to do or not to do. Sometimes you're

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Speaker 1: worry that people with mentastass might feel that there's nothing

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Speaker 1: that can be done. But we're better and better at

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Speaker 1: this over the years, and even since I started at

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Speaker 1: Cedar Sina twenty years ago, things are different than before,

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Speaker 1: so things are more treatable. We have better tools at surgery,

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Speaker 1: have better treatments, more targeted agents and immunotherapy. So it

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Speaker 1: wasn't like that when I started that. We had people

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Speaker 1: brame my task diase around for a long period of time,

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Speaker 1: but now there are there are people that I have

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Speaker 1: even past ten years with a diagnosis or brain metast disease.

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Speaker 1: It's different than it used to be. Sometimes we meet

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Speaker 1: people that are a little bit reluctant for different treatments

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Speaker 1: like radiation. So people are scared by the dea of

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Speaker 1: radiation and probably more than scared by the idea of

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Speaker 1: radiation or their brain. Part of what we do for

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Speaker 1: target radiation is that we focus really tightly around the

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Speaker 1: tumor target, and then we distribute the beams of radiation

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Speaker 1: around multiple parts of the brain such that each part

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Speaker 1: of the brain can tolerate the dose. So it's kind

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Speaker 1: of like if you have two flashlights focus on a target.

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Speaker 1: It's more intense at the center, but if you do

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Speaker 1: that thousands of times, you get this intensity at the

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Speaker 1: tumor site, but the rest of the brain gets very

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Speaker 1: little radiation at all, And so we do to try

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Speaker 1: to make it safe. I mean, clearly, there's always a

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Speaker 1: little bit of risk with things like radiation, but we

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Speaker 1: try to limit that risk as much as possible, keep

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Speaker 1: the brain as healthy as possible. It is better than

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Speaker 1: it used to be that we can target these things

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Speaker 1: more precisely, really the sub millimeter accuracy than we used to.

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Speaker 1: Sometimes we meet patients that are very reluctant to treatment,

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Speaker 1: and there are lots of people out there with stories

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Speaker 1: on chemotherapy. I think that some of these stories are

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Speaker 1: really older stories. I think it's tricky to go on

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Speaker 1: the internet sometimes, not that I don't want people to read.

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Speaker 1: I always appreciate what people read, just we have to

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Speaker 1: take everything with a grain of salt. And on the

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Speaker 1: Internet it's a lot harder to tell what your source

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Speaker 1: of information is. You know, in a store, it's very

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Speaker 1: easy to tell the difference between the Wall Street Journal

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Speaker 1: and the National Enquirer. But on the Internet it's different.

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Speaker 1: So sometimes we're really just reading some one person's particular

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Speaker 1: response to all the stuff, and you know, rarely people

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Speaker 1: aren't even telling you all the things and telling you

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Speaker 1: the total truth. Right, So generally get a little bit

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Speaker 1: better information from curated sites like them American Cancer Society

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Speaker 1: or our website I think has good information. Sometimes we

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Speaker 1: want to gauge that and really weigh the source of

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Speaker 1: the information. Even your favorite restaurant has a bad review somewhere,

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Speaker 1: that doesn't mean that you don't like it anymore. And

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Speaker 1: then I think the one difference too is that the

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Speaker 1: chemotherapies have gotten better. So really in this umbrella of

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Speaker 1: chemotherapy are more and more targeted therapies. As we do

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Speaker 1: more testing and find more molecular signatures of these cancers,

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Speaker 1: sometimes we can find a particular driver that we can

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Speaker 1: develop a drug to. So some targeted therapies will take

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Speaker 1: advantage of that hurt to our cells and get into

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Speaker 1: them in a certain way because of that. One example

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Speaker 1: for a breast cancer is people that are hurt too

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Speaker 1: positive that there are targeted agents for that that this

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Speaker 1: her too positive is a different little different than a

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Speaker 1: triple negative breast cancer, and we can use different treatments

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Speaker 1: for some of these people. I think another major improvement

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Speaker 1: over time has been this idea of immunit therapy. So

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Speaker 1: immunotherapy is medicine to emulate your immune system or fight

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Speaker 1: a tumor better. There's a lot of tumors that try

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Speaker 1: to hide from the immune system, and primary brain temors

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Speaker 1: can hide from the immune system by both down regulating

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Speaker 1: signals that our immune sysm uses to detect foreign things

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Speaker 1: like tumors, and it also sends out signals to suppress

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Speaker 1: your immune cells. But the goal of immuni therapy is

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Speaker 1: medicine to try to stimulate that to reverse itself. I

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Speaker 1: guess I should clarify. There is like medicine immune therapy,

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Speaker 1: there's also cellular imunotherapy like vaccines. Vaccines oftentimes are taking

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Speaker 1: tumor proteins and stimulating them with your immute white blood

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Speaker 1: cells to fight them better. But it's a little harder

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Speaker 1: to do all that stuff. It requires to recent surgery.

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Speaker 1: And then there's a part where the immune systems you

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Speaker 1: have to raise cells to develop into ones that recognize

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Speaker 1: foreign proteins and things versus you know, medical emunit. Theor

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Speaker 1: wich is a medicine we can give you, but sometimes

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Speaker 1: we have to sit down a lot with patients and

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Speaker 1: really try to give as much information as we can

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Speaker 1: and dispel some of these myths that are out there. Well,

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Speaker 1: it's been a pleasure to sit down with you and

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Speaker 1: answer great questions. Keep your questions coming, you want to

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Speaker 1: help you answer them. In the spirit of Breast Cancer

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Speaker 1: Awareness Month, make sure you keep up with mammograns merely checkups.

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Speaker 1: This is doctor Cheu, see you next time.